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Topic: Ethical, legal or illegal (Read 2683 times)

I am new to billing and the facility I work for has hired a contracted physician. We are waiting on reassignment of his Medicare and Medicaid with our facility tax ID#.Upper management is wanting to ask the Physician to have his office/billing service file claims for his services performed at our facility and him in turn reimburse our facility for payment on claims we can not bill for.The other biller and I are very leery if this is ethical, legal or just plain fraudulent.Any advice and/or suggestions are greatly appreciated.

...We are waiting on reassignment of his Medicare and Medicaid with our facility tax ID#.

Do they want the hired doctor to bill for his own work only until the assignment of his Medicare and Medicaid is effective? There are several ways to respond to this, depending on how you answer this question.

The doctor was hired & started back in August to render services at our facility and we would bill and receive payment for those services. The doctor has been added to our roster for commercial insurances and I have already billed those insurances for his services. Just not Medicaid, as we are still awaiting reassignment of benefits for Medicare then Medicaid. He is a pediatric specialist, so there will be no claims submitted to Medicare, just Medicaid.

Management realized they put the cart before the horse, so to speak, hiring him so quickly without waiting for the proper credentialing and are now wanting his office/billing company to bill for the services rendered at our facility for just Medicaid.

Red flags keep popping up and I am uncomfortable with this and appreciate any advice given on how to handle this situation and protect myself if in fact this is illegal.

A doctor can work on his own behalf, and bill on his own behalf. He can also hire other doctors to work for him and pay them a salary, and bill to receive payment for the work done by the hirelings. In this case, the hiring doctor is the billing agent. It is to him that all payors will submit payment, based on their contracts (or lack of them) with that billing agent (the hiring doctor).

Conversely, a doctor, without giving up his right to work for himself and bill on his own behalf, can hire himself out to another doctor or legitimate medical organization. A legitimate medical organization can hire doctors and pay them a salary, and bill to receive payment for the work done by the hirelings. In this case, the hiring organization is the billing agent. It is to the organization that all payors will submit payment, based on their contracts (or lack of them) with that billing agent (the hiring organization).

In your case, the only issue is whose Medicaid patients your hired doctor will be seeing. If he is seeing patients that frequent your facility, they should have already assigned their benefits to your facility. In this case, your facility can bill for the services performed by the hired doctor with no problem. Medicaid will pay your organization, based on whatever contract it has with them (or doesn't have). Your organization will pay the hired doctor his agreed-upon salary for the work he performs.

On the other hand, if the hired doctor is bringing patients with him, they need to reassign their benefits to your facility in order for your facility to get paid (otherwise, payment will go to the patients, and you will have to try to get payment from them).

It does not appear that your hired doctor needs to bill for his services to the Medicaid folks he sees, although he could. If he did bill himself, as the billing agent, he would just need to put your organization's address as his place of service. The assignment of benefits is actually irrelevant - other than, if Medicaid pays the patient, the doctor probably won't ever collect payment. Medicaid rules vary from state to state, so you would need to check with your state Medicaid program about this. They maybe need to have been notified of his additional place of service (your organization) before he can list this as a place of service on his CMS 1500 Forms. On the other hand, if he saw the patients at your location, he can get in big-time trouble if he lists his private practice as the place of service on the CMS 1500 Forms - should he decide to bill himself.

I see nothing in what you've said that would prevent your organization from billing, as the billing agent, for all services rendered by the hired doctor. The logic for this is laid out below.--------------

Here is some background information. If any of this is confusing, ask more questions.

I assume your organization, the one that is doing the hiring, has its own Taxpayer ID Number and Type 2 NPI Number. If you don't know, you need to find out. If your organization does not have these, let us know. The following applies (and makes sense) only if your organization is structured as the billing agent and has its own Type 2 NPI Number for billing purposes.

The question of reassignment arises only when assigned payment is made to someone other than the physician or other practitioner or supplier that furnished the services.

A supplier may be an individual, partnership, corporation, trust, or estate. Any services furnished by an employee of the supplier are considered furnished by the supplier if those services are within the scope of the employment. [end quote]

Doctors groups may hire physicians and pay them a salary. A doctor who has incorporated may hire physicians and pay them a salary. A doctor acting as a sole proprietorship may hire physicians and pay them a salary. All work done is billed under the name of the hiring group or physician. The hiring group or physician gets paid and then pays the hireling(s) a salary.

One of the points of the NPI numbers was to make this relationship more clear to CMS. Hence the Type 1 (who did the work) and Type 2 (who gets paid) NPI numbers. Both must be used on the CMS 1500 form that is submitted to Medicare. One tells CMS who did the work, and the other tells CMS who gets paid. In the case of a solo practitioner, both of the NPI numbers provided on the CMS 1500 form belong to him. In the case where the work was actually performed by a hireling, the CMS 1500 form must contain the Type 1 NPI number for who did the work (the hireling), plus the Type 2 NPI number for who gets paid (the hirer).

On the CMS 1500 Form, the Type 2 NPI number for who gets paid goes in Box 33. The Type 1 NPI number for who did the work goes in Box 24J. The Type 1 NPI number for the referring doctor (if any) goes in Box 17a. This is how we do it and we have no problems getting paid.

tallmanusa - I'm not clear on what you are saying. So, to clarify - as long as you have the following paragraph correct, then we are good here.

When you sign a contract, it should be signed with the billing entity. That is, it should be signed with the owner of the Type 2 NPI Number that goes in Box 33a of the CMS 1500 Form. If the owner of that NPI is a legal entity rather than a natural person (Doctors Group, Corporation, LLC, etc.), your contract should be signed by whoever is authorized to bind that legal entity in contracts. All billing work from that entity that you submit for payment should have the legal entity's Type 2 NPI Number (who gets paid) in Box 33a of the CMS Form 1500. However, you should also be given the Type 1 NPI Number of the doctor who actually did the work. For Medicare billing, and maybe other payers, this Type 1 NPI Number is required to be in Box 24J of the CMS 1500 Form.

A Providerís main site NPI number may not be assigned to any other Provider site. >>

So I would think that the suggested idea would not work. When you say reassignment, you are saying changing his address info. His NPI is now connected to one location and it is in process to be moved to another location. Right? So, this is a change of address that needs to be done through the correct channels..unless I am misunderstanding.

Merry - I'm not certain what you are saying or asking. We are not discussing assigning or re-assigning NPI Numbers in this thread.

A doctor in private practice may have multiple locations where he does business on his own behalf. That doctor uses his Type 1 and Type 2 NPI Numbers at all his business locations. These locations need to be registered with Medicare and other carriers. Assuming that patients have assigned their payments to the doctor, payment for work at any of these registered facilities would go to the address connected to the Type 2 (who gets paid) NPI number on file with CMS

A doctor can hire himself out to, for instance, a doctors group that is a legitimate legal entity. This legal entity would be the billing entity and would have its own Type 2 NPI Number (who gets paid) - which is used in Box 33a for all billing done on behalf of the work done by that doctors group. That billing entity would also need to acquire Type 1 NPI Numbers (who did the work) for all hirelings / owners who do work for that doctors group.

So - Merry, assume you are a doctor. You could do work at you own place(s) of business and bill for that work using your own Type 2 (who gets paid) NPI Number and Type 1 (who did the work) NPI Number. You could also do work at the doctors group that has hired you. That doctors group would pay you a salary. They would also bill for the work you did by using their Type 2 (who gets paid) NPI Number and your Type 1 (who did the work) NPI Number that they obtained for you as an employee / owner of that legal entity. You could theoretically work for a number of different doctors groups - and each would be required to obtain a Type 1 NPI Number for you - to use when billing for the work you did at that particular doctors group. So - no re-assignment of NPI Numbers anywhere.

Each doctors group / legal entity for which you do work, and which is also the billing entity, would need to add you as an owner / employee of that entity to the list they have on file with Medicare, and other carriers, depending on each carrier's requirements.

Now consider the assignment of Medicare payments for the Medicare patients you have in your private practice. To keep things simple here, the Medicare payments are actually assigned to the Type 2 NPI Number (who gets paid) and the address info connected to that NPI Number at CMS. If you get hired by a doctors group but you wish the assignment of payment for work done in your private practice to still go to your Type 2 NPI Number, you would do nothing. But if a condition of employment by the doctors group is that you transfer assignment of Medicare payment to them as the billing entity, then you (in conjunction with your patients) would request that Medicare change the assignment of your patients' payments to the Type 2 NPI Number (who gets paid) of the doctors group. That process can take up to six weeks to complete.

This is an issue only if patients from your private practice are going to come to the doctors group that has hired you. If you are only going to see patients at the doctors group that have already assigned their payment to the medical group, transfer of assignment is not an issue.

Merry, I'm assuming you already know this?? I'm writing for those who may not know. And, as I am trying to stay general rather than specific here, and as I don't know everything, I may have left out something important. I leave it to others to point out the pieces I may have missed or should have included in this discussion.

I also thought that as far as NPI numbers, each physician has one and only one NPI number and that is his/her OWN NPI number. THey do not get another one depending on who they work for, it just gets billed under the employers type 2 npi.

When you go to the NPI registry, each physician only has 1 NPI, not one for each place he works.

Also, just to clarify, if a physician is a sole proprietor and is not billing for anyone else, he only needs one NPI, his own personal NPI. He does not need a type 2 NPI if he is not incorporated.

... if a physician is a sole proprietor ... He does not need a type 2 NPI if he is not incorporated.

Correct. If the physician is not incorporated. All of our clients are sole proprietors in private practice and all are incorporated. Therefore, all need and use two NPI Numbers.

This is my statement from above: That billing entity would also need to acquire Type 1 NPI Numbers (who did the work) for all hirelings / owners who do work for that doctors group. I need to review my information on NPI Numbers, as I was typing off the top of my head last night. I seem to remember that, at one point, that was a true statement, but maybe it is no longer true - or maybe my application of that point is incorrect. I read a lot leading up to the implementation of the NPI Numbers, and after they were implemented. There were a number of changes in requirements made leading up to implementation, and some changes made after implementation - changes that messed up some of our clients good for a while. I may be remembering a proposal that was not implemented, or implemented and then changed.

But this discussion of the NPI Number process is getting way outside the realm of the original question.